Myanmar's coup risks a flood of vaccine-preventable disease

www.jogh.org • doi: 10.7189/jogh.12.03060 1 2022 • Vol. 12 • 03060 In line with the Sustainable Development Goals (SDGs), the reduction of the under-5 mortality rate to ≤25 deaths per 1000 live births by 2030 is the primary target of Myanmar’s national strategic plan for newborn and child health [1]. Myanmar made considerable strides in decreasing under-5 mortality with a 61% reduction between 1990 and 2019; however, the rate remained high at 45 per 1000 live births as of 2019 and more progress is needed [2]. In Myanmar, more than 45 000 under-5 children died in 2017 primarily due to newborn causes (46.7%), pneumonia (15.1%), diarrhea (8.7%) and injuries (8.5%) [2]. Because immunization is one of the most cost-effective and efficient ways to improve child health [3], Myanmar’s 1978 Expanded Program on Immunization (EPI) [4] was later broadened between 2016 and 2020 to include pneumococcal conjugate vaccines (PCVs), Japanese encephalitis (JE) and rotavirus vaccines [5]. Since then, EPI has been supplying nine types of vaccines for children in Myanmar (Table 1) [4,5].

I n line with the Sustainable Development Goals (SDGs), the reduction of the under-5 mortality rate to ≤25 deaths per 1000 live births by 2030 is the primary target of Myanmar's national strategic plan for newborn and child health [1]. Myanmar made considerable strides in decreasing under-5 mortality with a 61% reduction between 1990 and 2019; however, the rate remained high at 45 per 1000 live births as of 2019 and more progress is needed [2]. In Myanmar, more than 45 000 under-5 children died in 2017 primarily due to newborn causes (46.7%), pneumonia (15.1%), diarrhea (8.7%) and injuries ( The launch of EPI was followed by dramatic improvements in vaccination coverage in Myanmar (Figure 1). Even during the COVID-19 pandemic in 2020, vaccination coverage for tuberculosis, diphtheria, tetanus, pertussis, hepatitis B, measles, rubella, and polio was greater than 80%; the target coverage rate of 88% for 3 doses of the pentavalent vaccine (diphtheria, tetanus, pertussis, Haemophilus influenza type b, and hepatitis B) and oral polio vaccine (OPV) was reached successfully (Figure 1) [5]. Vaccine coverage for most childhood vaccine types in Myanmar was tracked with approximately corresponding rates to neighboring Bangladesh until the coup d'état happened in 2021 (Figure 1) [5]. EPI was suspended in many areas across Myanmar due to the subsequent unrest after the coup and the military's brutal post-coup crack-

Myanmar's coup risks a flood of vaccinepreventable disease
We are calling on the global health community and the Myanmar military to implement urgent and sustainable actions to prevent children from dying from vaccine-preventable diseases before outbreaks are too advanced to control and spill over into surrounding nations.
Due to the political turmoil that ensued after the coup and the Myanmar military's post-coup crackdown on civilians, Myanmar's fragile health system has collapsed. Consequently, childhood vaccination rates in 2021 dropped by 50% or more for many vaccine types, raising the risk of outbreaks of vaccine-preventable diseases. As of May 2022, almost 700 000 civilians, including women and children, have been internally displaced (IDP) by crises related to the military coup [7]. UNICEF estimates that five million children in Myanmar need humanitarian assistance [7]. Many internally displaced children are living in overcrowded conditions in IDP camps where they cannot access essential health services, including immunization [7]. These children are at risk of malnutrition and may lack access to clean water and sanitation facilities [7]. Furthermore, the outbreak surveillance system collapsed amid the conflict [6,7]. Poor camp conditions, in conjunction with disruptions in the provision of and access to health care, have further highlighted the need for robust immunization programs. Failure to take immediate action may leave a generation of children at risk of serious health outcomes even if the political turmoil were to pass.
Overall declines in vaccine coverage in Myanmar not only impart health risks to children who cannot access immunizations. but also threaten the health of their communities. A key component of preventing disease outbreaks is the achievement of herd immunity [8]. Despite Myanmar's declaration of polio-free status in 1996 [9], the risk of an outbreak of vaccine-derived poliovirus (VDPV) remains a concern when polio vaccine coverage becomes low. Since all types of childhood vaccine coverage became extremely low in 2021 [5], we are seriously concerned about the potential for outbreaks of vaccine-preventable diseases (VPDs), as was seen during the Syrian civil war with the emergence of polio outbreaks that even crossed borders into Iraq [10]. Myanmar is similarly at risk today, but the implications of VPDs resurging in IDP camps are not limited to Myanmar alone: cross-border spill over constitutes a significant global health concern.
The administrative responsibility of EPI is shared by multiple stakeholders
Funding: The present work was supported in part by grants from the Ministry of Education, Culture, Sports, Science and Technology of Japan (21H03203).
Authorship contributions: KSL and CG drafted the article. KLW, SG, SN and MH revised it critically for important intellectual content.

Disclosure of interest:
The authors completed the ICMJE Disclosure of Interest Form (available upon request from the corresponding author) and disclose no relevant interests.
the global health community that the military coup threatens the health and human security of Myanmar and its neighbors [11]. Myanmar was devasted by a catastrophic third wave of COVID-19 from July to September 2021. Due to the collapse of the public health care system and obstruction of health care by the Myanmar military, thousands of people died without getting access to needed health care [12][13][14]. There is clear evidence that children are suffering from the consequences of the collapse of Myanmar's fragile health system.
Urgent and sustainable action is required to prevent children from dying from VPDs before outbreaks are too advanced to control and spill over into surrounding nations. First, we reiterate our call to the Myanmar military to 1) immediately stop all forms of violence against civilians, including against health care workers and health infrastructure, 2) allow health services to resume throughout the country, including in IDP camps, 3) ensure safe and unimpeded access for international and local aid organizations to provide health and humanitarian assistance to IDPs, and 4) cooperate with multiple stakeholders to provide equitable access to health services (including childhood immunization) for all people in Myanmar, especially those in IDP camps who can only be reached by ethnic and community-based organizations or non-governmental and UN entities. We firmly call on UN organizations and the global community to ensure the full implementation of UN Security Council Resolution 2286, which strongly condemns attacks on health care personnel in conflict situations [15], and to fully adopt necessary measures to enhance the protection of and access to health care in Myanmar. We hope that UN and international organizations will negotiate with relevant parties to establish safe corridors to deliver essential health interventions, such as childhood immunization, ensure a continuous supply of vaccines and other commodities to sustainably provide childhood immunization and other essential health services, and support integrated outreach strategies ensuring that essential health services reach those in need. If the global community fails to act in a timely and compassionate manner, we may be reminded yet again that communicable diseases do not respect borders, and local health is ultimately global health.